competency in school nurse practice

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competency in

school nurse practice

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connecticut state

department of education

mark K. mcQuillan, commissioner

George a. coleman, deputy commissioner

division of family and student support services charlene russell-tucker, associate commissioner

Bureau of health/nutrition, family services and adult education paul flinter, chief

cheryl-ann resha, r.n., project manager

publications unit

donald G. Goranson, Jr., editor andrea Wadowski, Graphic designer Janet montague, desktop publisher

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competency in

school nurse practice

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this document is available on the

connecticut state department of education Web site at:

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c

ontent

s

Acknowledgments ... iv PrefAce ... v IntrodUctIon ... 1 Purpose ...1

Highly Qualified Professionals ...1

comPetencIes ... 2

Definition ...2

Overview ...2

Benner’s Application ...3

How to Use the Competencies ...4

School Nurse Competencies ...5

sUPerVIsIon ... 20

Overview ...20

Supervision Requirements ...20

Differences between administrative and clinical supervision ...20

Models of supervision ...21

Clinical supervision ...21

Supervision by non-nursing personnel ...21

Regional supervision ...21

Peer/group supervision ...22

Peer mentoring ...22

Professional Development ...22

Additional Roles of the Supervisor ...23

eVAlUAtIon ... 24

sUmmArY ... 25

references ... 26

resoUrces ... 28

APPendIX A. School nurse competencies tool ...29

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a

ckno

wledgment

s

This document was developed through the cooperation of numerous professionals committed to improving the quality of school health services in Connecticut. The Connecticut State Department of Education (CSDE) extends its thanks to the following task force members for their collaboration, expertise and perseverance.

Nancy Bafundo, Chair, Connecticut Board of Examiners for Nurses JoAnn Boulden, Nursing Supervisor, Madison Public Schools Joan Cagginello, Nursing Administrator, Milford Health Department Donna Kosiorowski, School Nurse Supervisor, West Haven Public Schools Pat Krin, Nursing Administrator, Newington Public Schools

Suzanne Levasser, School Nurse Supervisor, Danbury Public Schools

Berndatte Madero, Nursing Professor, Southern Connecticut State University Liza McMahnon, School Nurse, Hartford Public Schools

Carole Passarelli, Nursing Supervisor, Area Cooperative Educational Services Pat Piatek, Nursing Supervisor, EASTCONN

Nadine Schwab, Nursing Administrator, Westport Public Schools

Martin Sklaire, MD, School Medical Advisor and Chair of CT AAP School Health Council Alice Stockton, Nursing Supervisor, Capitol Regional Education Council

A special thank you is extended to Ruth Kirsch, consultant for the State Education Resource Center and her organization for their commitment and expertise in facilitating the work of this group and school nursing.

The CSDE would also like to recognize Vicki Taliaferro, school health consultant, for her expertise and knowledge in the development and review of this document.

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pref

a

ce

School nurse practice “is grounded in respect for person, family and other groups and communities and guided by explicit focus of nursing. Nurturing children, promoting their well-being to accommodate their hopes and dreams – including success in school – requires creative integration of multiple ways of knowing and involves understanding, through synthesis of information, within the dynamic context of values and health practice” (Aiken, SREB, 2000; Parker and Berry, 1999).

rAtIonAle

Evidence confirms what school nurses know: children are now attending school with more complex health needs, and the frequency of chronic health needs has increased significantly over the last two decades (ANA, 2007; NASSNC, 2007). In order to assure safe and high-quality health care in the educational setting, school nurses now need expanded skills and knowledge in order to meet the growing needs of students.

In addition to the knowledge and skills needed by the individual school nurse, clinical supervision is essential in ensuring safe care. At present, many school nurses do not have access to regular, ongoing clinical supervision. According to the National Association of School Nurses (2003), “It is essential to provide supervision and evaluation of school nurses by school nurses knowledgeable in school nursing practice, supervision and administration, and that evaluations should be based upon standards of professional school nursing practice.” The National Association of State School Nurse Consultants (2007) believes that schools have a responsibility to provide safe and high-quality health services, and that these services require clinical supervision by a school nurse manager/ coordinator or supervisor.

How to Use tHIs docUment

This document is intended to be used by individual school nurses, their school nurse supervisors and school administrators. It is divided into three sections: competencies, supervision and evaluation.

The competencies are designed to identify the skills and knowledge needed to ensure safe and high-quality health care. These competencies may be used in a variety of ways:

• A framework for nursing school instructors;

• An orientation plan for new school nurses;

• An evaluation tool by nursing supervisors;

• A self-evaluation tool for school nurses;

• A goal-setting tool for school nurses; and

• A program planning tool (See How to Use the Competencies on page 4).

The section on supervision can be used to explore the role of the supervisor, the need for clinical supervision, and the difference between clinical and administrative supervision.

The last section of this document includes the rationale for evaluation and potential components of an evaluation. A sample evaluation tool included in the Appendix is based on the school nursing competencies. This checklist can be used to assess the school nurse’s competency levels and can be used for periodic evaluation of the school nurse.

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intr

oduction

PUrPose

This document is designed to support the practice of school nursing within Connecticut schools. The areas of school nurse competency, supervision and evaluation are presented in an effort to promote high-quality school health services. In alignment with the national standards of Professional School Nurse Practice (ANA and NASN, 2005), the school nurse competencies delineate the knowledge and skills needed to practice nursing in the school setting. These guidelines also align with Connecticut’s Common Core of Teaching (1999) and the underlying tenets of professional growth and professional development. With input from a broad spectrum of school nurses, including school nurse supervisors, higher education and the Connecticut Board of Examiners for Nurses, these guidelines reflect the standards, research and best practices in the field of school nursing.

HIgHlY QUAlIfIed ProfessIonAls

The U.S. Department of Education cites highly qualified professionals as a major objective of the No Child Left Behind Act of 2001 to ensure that all students have the best teachers possible, and further states that research demonstrates a correlation between student achievement and teacher quality. The Connecticut State Department of Education supports the position that all individuals providing services for students should be highly qualified professionals, including school nurses. It is expected that school nurses, just as teachers, demonstrate competencies in order to provide Connecticut students with quality health services from the most highly qualified professional school nurses.

One of the three requirements of the highly qualified professional is demonstrated competency. This document provides the defined competencies for a school nurse. To paraphrase Whitehurst (2002) “Quality is affected by general knowledge and ability; certification and licensure; experience, subject matter knowledge, intensive and focused in-service training, alignment between (nurse) training and standards-based reforms.”

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c

ompetencies

defInItIon

Competence, as used in this document, is defined as “ongoing professional nursing competence according to level of expertise, responsibility and domains of practice as evidenced by behavior based on beliefs, attitudes and knowledge matched to and in the context of a set of expected outcomes as defined by nursing scope of practice, policy, Code of Ethics, standards, guidelines and benchmarks that assure safe performance of professional activities (American Nurses Association, 2000; Whittaker, Carson and Smolenski, 2002).

This definition emphasizes that the school nurse must use his or her core knowledge and skills and be “able to apply that knowledge and those skills to benefit the health and educational success of the school-age child.” (Bobo, Anderson and Cooper, 2002)

oVerVIew

Competencies exist for any number of specific disciplines. For several decades, professional organizations have emphasized the need for professional competencies. “In recent years a growing number of nursing organizations, education programs, regulatory and advisory bodies, and accreditation authorities have put increased emphasis on the objective measurement of outcomes in academic and practice settings.” (Bargagliotti, Luttrell and Lenburg, 1999)

The American Nurses Association (ANA) empowered a panel of experts to consider nursing competencies and to formulate the following assumptions regarding continuing competence in nursing (American Nurses Association, 2000; Whittaker, Carson and Smolenski, 2002). The purpose of ensuring continuing competence is protection of the public and advancement of the profession through the ongoing professional development of nurses. Competency assumptions follow.

• The public has a right to expect competence throughout nurses’ careers.

• Any process of competency assurance must be shaped and guided by the profession of nursing.

• Assurance of continuing competence is the shared responsibility of the profession, regulatory bodies,

organizations/workplaces and individual nurses.

• Nurses are individually responsible for maintaining continuing competence.

• The employer’s responsibility is to provide an environment conducive to competent practice.

• Continuing competence is definable, measurable and can be evaluated.

• Competence is considered in the context of level of expertise, responsibility and domains of practice.

Continuing competence contributes to the quality of nursing practice. The ANA continues to examine the issue of nurse competencies “to assure continuing competence in today’s environment, where technology and practice are continually changing, new health care systems are evolving and consumers are pressing for providers who are competent.” (Whittaker, Carson and Smolenski, 2002)

eVolUtIon of scHool nUrse comPetencIes

In 2000, the Southern Regional Education Board (SREB), a nonprofit, nonpartisan organization that works with educational leaders and policymakers in 16 member states to improve pre-K through postsecondary education, worked with nurse educators and school nurse leaders to develop a framework of core competencies for school nurses (SREB, 2000). It was acknowledged that school nursing is a specialty practice within the nursing profession and that nursing educators required this framework to guide the preparation of school nurses.

Building on the work of the SREB, the National Association of School Nurses partnered in 2001 with the National Consortium of School Nurse Educators, the American School Health Association, the National Association of State School

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Nurse Consultants and invited national experts to move the school nursing competencies forward, acknowledging not only the need for core competencies for the beginner nurse, but to expand it to school nurses with a variety of experience (Bobo, Anderson and Cooper, 2002). That work continues.

The Connecticut State Department of Education (CSDE) has responded to the need to provide a set of expanded competencies that define school nursing practice at several levels. These competencies are based on Benner’s Application of the Dreyfus Model of Skill Acquisition to Nursing (1984).

Benner’s APPlIcAtIon

In Benner’s original application, the skills of a nurse are based on a five-tiered continuum from novice to expert. In this CSDE document the competencies for school nurses are outlined in a four-tiered continuum from the emergent level to the expert level. The novice nurse, the first tier on the Benner continuum, addresses the undergraduate nurse and, therefore, does not apply to school nurses. The application posits that in the acquisition and development of a skill, a student passes through levels of proficiency and these different levels reflect changes in skilled performance. Permission for the CSDE adaptation of the following continuum was granted by Patricia Benner, R.N., Ph.D., of the University of California at San Francisco:

emergent school nurse

The emergent school nurse can demonstrate marginally acceptable performance. Through practical experience in concrete situations, the emergent school nurse starts intuitively to recognize various aspects of a situation when they are present. These aspects require prior experience in actual situations for recognition. Principles to guide actions begin to be formulated. The principles are based on experience, skills and knowledge as part of one’s professional education and preparation as a nurse, and as evidenced by licensure as a registered nurse with the state.

competent school nurse

Competence is achieved when the school nurse, through instruction or experience, begins to adopt a hierarchical perspective. Typically, the competent school nurse has been on the job in the same or similar situation two or three years. The competent school nurse devises a plan based on considerable conscious, abstract and/or analytic contemplation of the situation he or she is facing. School nurses have to decide for themselves which plan to choose without being sure that it will be appropriate in a particular situation. The competent school nurse, after making a decision, feels responsible for his or her choice and its results.

Proficient school nurse

Proficient school nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient school nurse learns from experience what typical events to expect in a given situation and how plans may need to be modified in response to these events. This response is not yet automatic, as the proficient school nurse has yet to have enough experience with the wide variety of possible actions in each situation. In order to determine the correct response, the school nurse falls back on the detached, rule-based determination of actions.

expert school nurse

The expert school nurse no longer relies on an analytic principle (rule, guideline, maxim) to connect her or his understanding of a situation to an appropriate action. The extensive background of the expert school nurse fosters an intuitive grasp of each situation and identification of the nexus of the problem without wasteful consideration of many alternative diagnoses and solutions. “They do what in experience has normally worked, and naturally, it normally works” (Benner, Tanner and Chesla, 1996). The expert operates from a deep understanding of the whole situation. Although the expert’s performance is ongoing and nonreflective, she or he thinks before acting, reflects upon the goal or perspective that seems evident, and upon the action that seems appropriate to achieving the goal. The expert school nurse sees intuitively what to do without applying rules and making inferences.

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How to Use tHe comPetencIes

These competencies are intended to be used for the following purposes:

• A framework for nursing school instructors. Nursing education, course work and clinical experiences need to incorporate core content and skills to ensure that graduating nurses are well prepared as school nurses (SREB, 2000). These competencies can assist nursing school instructors to develop curriculum that can prepare nursing graduates for entry-level competencies in school nursing practice.

• An orientation plan for new school nurses. While the orientation of school nurses should include basic information, such as an introduction to district policies and procedures, familiarity with data collection and nursing documentation, and how and when to access the nursing supervisor and available resources, these competencies allow the school nurse supervisor to establish basic expectations for the new school nurse’s performance. Competencies delineate the skills and knowledge required of the new school nurse and the content of an orientation can be guided by these competencies.

• An evaluation tool by the nursing supervisor. Competencies provide a framework for performance appraisal of the school nurse in the education setting (Bobo, Anderson and Cooper, 2002). Evaluation provides necessary objective feedback to the school nurse. The sample tool provided in this document is based on the competencies and standards of school nursing practice. Using the competencies as the basis for evaluation provides the nursing supervisor with a fair and consistent standard by which to evaluate all school nurses.

• A self-evaluation tool by the school nurse. Competencies may be used as a yardstick to measure professional growth (Bobo, Anderson and Cooper, 2002). Competencies provide the criteria and standards to measure one’s achievement and allow the school nurse to assess his or her performance. Self-evaluation represents a commitment of the school nurse to honestly evaluate his or her own performance, with the goal of increasing professional development and the quality of services provided.

• A goal-setting tool for school nurses. Once the school nurse has performed a self-evaluation and assessed her or his performance, setting goals will assist the nurse in reaching professional potential. School nurses who set their own goals, with the competencies as a guide, demonstrate motivation and professionalism. In partnership with a supervisor, the goals can be evaluated, setting the course for performance outcomes.

• A program planning tool. School health services programs can use the competencies to guide program standards and policies, develop professional training and assess program quality.

scHool nUrse comPetencIes

The school nurse competencies presume that some core knowledge has been provided to the school nurse by his or her supervisor. In developing these competencies, district policies and structures must be in place. These include an orientation at the district level, policies and procedures, a system or for data collection and nursing documentation, access to a nursing supervisor and peer networking opportunities. A tool that lists the competencies in a check-off format can be found in Appendix A of this document.

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standard 1: assessment

the school nurse collects, analyzes and synthesizes comprehensive data pertinent to the student’s health or the situation.

emergent comPetent ProfIcIent eXPert

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse:

Completes a program of orientation to school district policies, procedures and systems for data collection and documentation;

Demonstrates ability to access and follow policies, procedures, protocols and supervisory direction to guide practice in data collection;

Collects, prioritizes, documents and evaluates basic student health information during routine student visits to the health office and in emergency situations, according to established policies, guidelines and protocols;

Collects basic student health information as it relates to state-mandated screenings and physical exam data as directed by the clinical supervisor; Accesses consultation and supervision for setting priorities of data collection in more complex situations (for example: medically complex students; students not making educational progress; students with ongoing somatic complaints); and

Learns to use an already- established data collection system in an organized manner.

Initiates collection of data from students, parents, staff members, and health care providers as guided by protocols and procedures; With supervision, collects and analyzes focused and comprehensive data as indicated by student complaint, family concern/ request or school team request; Uses appropriate interview techniques with students, parents and staff members; Drafts health history assessment summaries for individual students in collaboration with clinical supervision; and

With direction, supervision and consultation collects, prioritizes, evaluates and documents data in more complex situations using prior and newly-acquired knowledge and skills in accordance with established policies, guidelines and protocols.

Independently collects, prioritizes, documents and evaluates individual and collective student health data guided by clinical judgment and current research information;

Synthesizes focused and comprehensive data according to student, program, school and community needs;

Uses a variety of modalities to collect and differentiate data, including observations, interviews, standardized assessment tools, outside sources and formal and informal settings with attention to cultural, environmental, educational and bio-psychosocial indicators;

Prioritizes data collection in routine and complex health and education situations based on prior experience and knowledge; Uses policies and protocols to help set priorities;

Actively contributes to a data collection system that is organized, ongoing and flexible according to student needs;

Evaluates and revises the process as indicated. Retrieves individual and aggregate data to inform practice, policy, procedures and program development; and Identifies need for and drafts health history assessment summaries for individual students with clinical consultation.

Empowers students to be partners in the data collection process by encouraging them to develop effective communication, self-advocacy and self-awareness skills; Intuitively prioritizes data collection and synthesizes the data in all situations through a variety of modalities;

Develops, implements and evaluates a districtwide data collection process that is organized, systematic and ongoing;

Uses the system for research purposes to develop best practice guidelines for the subspecialty of school nursing; instructs others; Designs, implements and evaluates data collection protocols for research initiatives in school health practice at the individual, group and community levels; and Independently produces and presents health assessment summaries for individual students for planning and program purposes.

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standard 2: diagnosis

the school nurse analyzes assessment data to determine the nursing diagnoses and collective problems.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse:

Assigns appropriate nursing diagnoses for individual students after analysis of assessment data during routine office visits and emergency situations; Consults frequently with a supervisor and proficient school nurse colleagues regarding the choice of nursing diagnoses in the routine and emergent care of students; and

For individual students, documents nursing diagnoses according to district procedures in order to facilitate expected outcomes and a plan of care.

Derives appropriate nursing diagnoses for individual students through analysis of a broad range of assessment data, including data from the student, family, school staff and health care providers.

Derives a variety of nursing diagnoses for individual students through a holistic assessment of the students within the educational environment and the families; and

Derives and validates appropriate nursing diagnoses for groups of students and for the school community.

Conceptualizes and explores implementation of new nursing diagnoses relevant to the care of the students and community in the educational environment; Proposes to accredited bodies, such as NANDA, new diagnoses relevant to the care of students and communities; and

Uses trends in student diagnoses to guide district planning for future programs.

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standard 3: outcomes identification

the school nurse identifies expected outcomes for a plan that is individualized to the student or the situation.

the emergent school nurse: Identifies expected short- term student health outcomes based on the nursing diagnoses that are developmentally appropriate; and

Possesses beginning awareness of the educational implications of health concerns or problems.

the competent school nurse: Identifies expected short- term student health and educational outcomes based on the nursing diagnoses;

With consultation, identifies outcomes that are culturally appropriate and realistic in relation to the student’s present and potential capabilities; Determines outcomes with consideration of resources that are needed and available; and Constructs and documents student health outcomes that are measurable and include a reasonable time frame.

the proficient school nurse: Identifies short- and long-term outcomes that are mutually formulated with the student, family, school staff, community and other providers, as appropriate;

Independently identifies outcomes that are culturally appropriate and realistic in relation to the student’s present and potential capabilities; Considers risks, costs, benefits and scientific evidence in the development of outcomes; Constructs and documents student health and educational outcomes that are measurable, expressed in educational terms and include a reasonable time frame; and

Serves as case manager for students with health needs.

the expert school nurse: Mentors proficient school nurses in the role of case manager for students with health needs; Identifies and uses trends in student outcomes to guide district planning for future school programs; and

Acts as a resource for the school community in the development of health and educational outcomes for students.

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standard 4: planning

the school nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.

the emergent school nurse: Establishes a plan of

interventions to meet the immediate needs of students making routine health office visits for wellness concerns, injuries and illnesses;

Communicates the intervention plan to the individual student; Documents the intervention plan in the student health record;

Recognizes and prioritizes students’ needs for

individualized health care plans; Initiates the individualized health care plan with the direction of the school nurse supervisor;

Documents the completed Individualized Health Care Plan (IHCP) according to district policy;

Differentiates the essential components of the health care plan, such as an emergency care plan, routine interventions, transportation plans, off-site plans and medication plans; and Collaborates with other school team and family members to develop individualized health care plans based on standardized health care plan templates.

the competent school nurse: Establishes a plan of

intervention to meet the immediate health promotion, education and developmental needs of students making routine health office visits; Seeks consultation from and makes referrals to other health and education professionals; Includes all the essential components in the development of the health care plan with guidance;

Collaborates with other school team and family members to complete an individualized health care plan; and

Recognizes program differences related to health care plans that are developed within the regular education, Section 504 and IEP.

the proficient school nurse: Integrates health promotion, education and prevention activities for students making routine health office visits; Integrates a self-care model into planning for routine health office visits based on a student’s developmental age and abilities; Collaborates with others in the school community to develop planned strategies to promote appropriate use of the health office;

Establishes an efficient system for documenting routine health office visits;

Uses current health care standards, trends and evidence-based information to develop health care plans in a timely manner;

Integrates the appropriate components into the health care plan as appropriate to the individual or group of students; Considers the impact of the potential recommendations on available school and family resources, such as staffing patterns and availability of equipment and supplies; Independently develops individualized health care plans within the appropriate educational programs (regular education, Section 504 and special education); and Uses professional consultation when appropriate in developing more complex individualized health care plans.

the expert school nurse: Develops a consistent district-wide approach to the planning for student and school community health needs; Provides district- and community-level guidance and consultation in the development of health care plans for students; Provides a global and research-based perspective to the process of planning for students with special health and developmental needs; and

Establishes a planning process that reflects all applicable federal and state laws and regulations, and professional standards of practice.

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standard 5: implementation

the school nurse implements the interventions identified in the plan of care/action.

the emergent school nurse: Provides interventions using the written health care plan and district policies, procedures and clinical protocols to address health needs;

Seeks supervision when considering revisions to an established plan of care; With supervision, provides education and direction to school staff members in carrying out specific aspects of the plan; and

Documents the nursing interventions in the appropriate health records according school district policies and procedures e.g., nursing notes, medication administration sheets, IHCP, Cumulative Health Record (CHR), etc.

the competent school nurse: According to the established health care plan, provides education and direction to school staff members in carrying out specific aspects of the plan; Coordinates the delivery and provides for the continuity of health-related supports and services as identified in the health care plan;

Documents implementation of the nursing interventions using standardized nursing language or equivalent terminology; and Documents the nursing interventions in the appropriate health and educational records according school district procedures, including the IEP.

the proficient school nurse: Collaborates with nursing and school staff members, community health care providers and community services, such as after-school programs, School Based Health Clinics (SBHCs), young parent programs, summer camps, etc.;

Identifies and implements changes or modifications in the plan of care;

Seeks scientific evidence through multiple information resources (such as reputable Internet sites, research-based and peer-reviewed journals, text books, etc.) to identify and implement nursing plans; and

Serves as an advocate for students, families and staff members on the implementation of care.

the expert school nurse: Serves as a mentor to other school nurses on appropriate implementation of plans of care; and

Uses creative thinking to advocate for the appropriate implementation of a plan with school administrators, families and health care providers.

standard 5a: coordination of care

the school nurse coordinates care delivery.

the emergent school nurse: Coordinates with other school personnel and families to carry out specific aspects of the plan by providing education and direction; and

Documents coordination of care in the appropriate health care records according to district policy (such as IHCP, nursing notes, 504 plan, etc.).

the competent school nurse: Works with colleagues to integrate the health care plan into routine school programs; and

Coordinates the delivery of and provides for continuity of health-related supports and services as identified in the health care plan.

the proficient school nurse: Incorporates the individualized health care plan into the student’s educational day; and Coordinates with families and community providers (such as coaches, after-school program directors, etc.) to promote transition of the health care plan goals into their extracurricular and community activities.

the expert school nurse: Promotes coordination of the plan with all agencies involved in the student’s care (such as DMR, DSS, DCF, community-based providers, etc.).

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standard 5B: health teaching and health promotion

the school nurse provides health education and employs strategies to promote health and a safe environment.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse:

Provides basic health Incorporates evidence-based, Integrates evidence-based Designs and evaluates health

information and counseling to developmentally appropriate health promotion concepts education strategies and

individual students related to health education and counseling into teaching and counseling programs to improve the

identified concerns within a to individual students during the with individual and groups effectiveness of health teaching

health office visit; health office visits; of students, such as healthy and counseling with individual

lifestyles, reducing risky and groups of students to meet

Gives consideration to Provides evidence-based health behaviors, bullying and violence their developmental, cultural,

developmental differences education and counseling to prevention, and other health linguistic and learning needs;

among students in their families based on students’ needs promotion activities based on

school when providing health as identified in the health office the Connecticut Healthy and Develops partnerships with

information; visit; Balanced Living Curriculum families and communities to

Frameworks; enhance the design and delivery

Acts as a resource to classroom Gives consideration to cultural of health education;

teachers when approached; and and linguistic differences among Seeks opportunities to provide

students in their school when evidence-based education and Conducts research to support

With guidance and supervision, providing health information; counseling to individual families and direct evidence-based

provides basic staff wellness and parent groups; practice in health education and

education (such as universal Serves as a professional health counseling;

precautions, flu prevention, etc.). resource in classroom instruction Seeks opportunities and provides

to enhance the curriculum and continual health education Designs a planned program

promote health literacy; to students by co-teaching or component to provide ongoing

serving as a classroom resource; _{student health education as a}

Begins to identify areas of need for health education and health instruction based on health office data; and

Promotes the integration of health topics into all areas of the school curriculum (e.g., math, reading, art, physical education, etc.);

part of the health education curriculum;

Initiates assessments and surveys to determine the areas

Promotes wellness among school _{Identifies areas of need for health} for individual teaching and

staff members based on staff _{education and health instruction} curriculum development in

concerns. _{based on student health data,} health education and health

community needs and youth risk instruction, collaborating with

behavior trends; health educators and curriculum

leaders; and Ensures that health and safety

are incorporated into all areas Designs districtwide staff

of the school environment, wellness programs.

such as serving nutritious foods, safe playground, safe social/ emotional environment, indoor air quality;

Participates with school staff members in the development and revisions of the health curriculum; and

Promotes and provides staff wellness programs and health information.

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standard 5c: consultation

the school nurse provides consultation to influence the identified plan, enhance the abilities of others and effect change.

the emergent school nurse: Identifies and obtains baseline data in response to a request for consultation; and

Seeks supervision to analyze data and provide appropriate consultation.

the competent school nurse: Analyzes and synthesizes information from a variety of sources;

Seeks supervision to ensure effective consultation; Identifies stakeholders and includes them in the decision-making process related to the health plan; and

Independently communicates recommendations and provides relevant consultation to school personnel and family members, as appropriate.

the proficient school nurse: Synthesizes data according to evidence-based practice and theoretical frameworks; Requests supervision, as needed, to promote effective consultation;

Initiates opportunities to provide consultation to others in order to influence the plan and enhance practice; and Independently communicates recommendations to, and facilitates understanding by, community-based providers and agencies.

the expert school nurse: Serves as a mentor and resource to others on effective consultation practices; and Develops models for effective consultation.

standard 6: evaluation

the school nurse evaluates progress toward attainment of outcomes.

the emergent school nurse: With supervision,

Uses a systematic approach to evaluate whether or not plans were implemented as specified; Involves the student and others to evaluate outcomes; Documents the results of the evaluation according to district policies and procedures; and Revises the plan as needed.

the competent school nurse: Independently,

Uses a systematic approach to evaluate whether or not plans were implemented, and specified health outcomes were achieved; Involves the student and others to evaluate outcomes; Documents the results of the evaluation according to district policies and procedures; and Revises the plan as needed.

the proficient school nurse: Evaluates whether student outcomes had the desired impact on educational progress; and Aggregates data from student outcomes to effect change to policies and procedures, and promotes school health programs that support student learning and healthy development.

the expert school nurse: Develops systems for outcome evaluation; and

Conducts research and publishes articles to advance practice in the field.

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standard 7: quality of practice

the school nurse systematically evaluates the quality and effectiveness of nursing practice.

the emergent school nurse: Collaborates with the supervisor to assess the quality of student care in the health office; Adheres to the district’s system for the collection of data which will be used to monitor the quality and effectiveness of nursing care;

Adheres to district policies, procedures and practice guidelines/protocols to promote quality of care;

Implements activities to enhance the quality of nursing practice as directed by the supervisor; and Appropriately documents all essential communications.

the competent school nurse: Implements activities to enhance the quality of nursing practice in collaboration with the supervisor; and

Participates in evaluation and research to test the quality and effectiveness of nursing care.

the proficient school nurse: Contributes to the development of research to determine the quality and effectiveness of nursing care;

Formulates recommendations to improve school nursing practice and/or student outcomes in collaboration with school administrators, boards of education and boards of health; Initiates changes in nursing practice at the building level based on the results of quality assurance activities; and Contributes to the development of policies, procedures and practice guidelines to improve the quality of care.

the expert school nurse: Develops policies, procedures and practice guidelines to improve the quality of care; Initiates changes in nursing practice at the district level based on the results of quality assurance activities; and Designs, implements and evaluates research to test the quality and effectiveness of school nursing practice.

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standard 8: education

the school nurse attains the knowledge, skills and competencies required for quality practice in schools.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse:

Demonstrates basic knowledge Applies knowledge and skills Pursues an advanced degree in Has an advanced degree in

and skills appropriate to the appropriate to the specialty nursing or a related field; nursing or a related field at the

specialty practice of school practices of school nursing; master’s level or beyond; and

nursing, including but not Seeks advanced knowledge and

limited to: Identifies personal needs for skills appropriate to the specialty Plans, designs and implements

• Knowledge of growth and

development;

• Pediatric and adolescent

primary care Issues;

• Infectious and communicable

diseases or infestations;

• Chronic disease management

for school-aged youths;

• School health laws and

professional development and ongoing formal education; Participates in appropriate professional development and higher education activities; and Acquires more in-depth knowledge related to:

practices of school nursing and the educational environment; and

Contributes to the design and implementation of professional development programs in school health at the local or state level.

professional development or higher education programs in school health at the local, state or national level.

regulations; • Special education;

• Family systems theory; • Section 504; and • Roles of school team • IHCP/IEP process.

members;

• Skills related to effective oral

and written communication;

• Information technology; and • Assessment of common

pediatric primary care problems;

Participates in continuing education activities to enhance current clinical knowledge and professional issues in consultation with a supervisor; and

Seeks clinical supervision to enhance their knowledge and skills in school nursing practice.

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standard 9: professional practice evaluation

the school nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse: Participates in performance

appraisal on a regular basis in order to identify strengths and areas for improvement; Uses constructive feedback from a clinical supervisor to improve one’s practice;

Develops annual goals and objectives in collaboration with a supervisor; and Implements performance strategies to achieve goals identified through the

Participates in peer review, as appropriate;

Seeks constructive feedback from a clinical supervisor regarding one’s practice;

Independently identifies professional strengths and areas for improvement; and In collaboration with a supervisor, develops annual goals and objectives to enhance performance.

Initiates and participates in peer review, as appropriate;

Collaborates with a supervisor to develop annual goals and objectives to enhance the district’s health services program; and

Contributes to the development and revision of the district’s performance appraisal process.

Develops and revises the district’s performance appraisal process; and

Mentors others in self- and peer-evaluation.

evaluation process.

standard 10: collegiality

the school nurse interacts with and contributes to the professional development of peers and school personnel as colleagues.

Understands the organizational Shares nursing knowledge and Contributes knowledge to the Researches and synthesizes

structure of the school and skills with nursing colleagues staff about the impact of health information on national, state

district and understands the role and begins to share with on academic achievement; and local issues and their impact

of other school staff members; interdisciplinary colleagues;

Seeks constructive feedback on health in schools; and

Contributes appropriately Seeks new knowledge and skills from nursing and education Provides mentoring

to nurse and faculty meeting from educational colleagues to colleagues; opportunities for nursing and

discussions; and enhance nursing practice; _{Provides peers with constructive} education professionals.

Explores participation in appropriate professional

Understands and supports contributions from other

feedback regarding their practice;

organizations. disciplines to the educational

processes; and

Suggests items for and presents school health information at faculty meetings.

Provides professional development to school personnel; and Provides educational opportunities for students of nursing and other professions, as well as other employees.

(23)

standard 11: collaBoration

the school nurse collaborates with student, family, school staff and others in the conduct of school nursing practice.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse: Seeks supervisory assistance to

identify, prioritize and establish cooperative relationships with:

• Core school;

• Core district staff; and • Essential community-based

partners;

With supervisory support, articulates for students, parents/ guardians and school staff members the school nurse’s role within a coordinated approach to support the health, learning and achievement of students; and

Seeks orientation about and accesses school district policies and procedures regarding standards to share and protect students’ health, mental health and educational information, both internally and externally, including obtaining appropriate authorizations.

Cogently articulates the nurse’s role and the importance of health services to support learning, health and achievement of students; and Independently establishes and maintains cooperative relationships within the school and community, based on ethical and legal standards permitted and through protected communications.

Models the nurse’s role and the importance of health services to support learning, health and achievement by students; Identifies and helps to resolve barriers to effective collaboration; and

Advocates for a collaborative approach to student supports and services.

Initiates multidisciplinary teams to promote collaboration; Builds consensus within the school community to achieve identified goals;

Collaborates with a multidisciplinary team to initiate systems change, develop policies and programs; and Mentors and supervises others in the collaborative process.

(24)

standard 12: ethics

the school nurse integrates ethical provisions in all areas of practice.

Uses the ANA and NASN Adheres to educational laws, Establishes a network of Develops policies, procedures

Codes of Ethics and school health care laws, nursing ethics, resources for consultation in and professional development

district policies to guide decision and federal, state and district resolving ethical dilemmas; activities that promote staff

making in his or her practice; regulations relating to privacy

and confidentiality; Facilitates exploration and

adherence to ethical standards related to:

Seeks a supervisor’s assistance in interpreting ethical standards as they apply to specific situations; Delivers care in a manner that preserves and protects the autonomy, dignity and rights of students and, when applicable, their families; Maintains therapeutic and

Delivers care in a manner that is sensitive to diversity within the school community; and Recognizes ethical dilemmas involving students, colleagues or systems and participates in resolving them with consultation.

resolution of ethical dilemmas of students, colleagues or systems; and

Educates others about therapeutic and professional student-nurse relationships and role boundaries.

• student autonomy, dignity

and rights;

• diversity within the school

community;

• educational laws, health care

laws, nursing ethics, and federal, state and district regulations;

• advocacy for students; and • staff wellness;

professional student-nurse relationships, including appropriate role boundaries, and seeks supervision as

Acts as a consultant to others to resolve ethical issues of students, colleagues or systems; and

necessary; and _{Contributes to the establishment}

Seeks orientation to educational laws, health care laws, nursing

and operations of an Ethics Committee for the district. ethics, and federal, state and

district regulations relating to privacy and confidentiality.

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standard 13: research

the school nurse integrates research findings into practice.

the emergent school nurse: Collaborates with a supervisor to seek and use evidence-based data from professional literature to guide practice decisions; and Participates in data collection (surveys, pilot projects, studies) as directed by the supervisor.

the competent school nurse: Uses evidence-based data to guide practice decisions and professional growth;

Identifies clinical issues for data collection; and

Participates on a formal committee or program (e.g., indoor air quality, crisis, wellness, school health advisory).

the proficient school nurse: Analyzes and synthesizes broad-based data to inform and guide clinical practice;

Identifies clinical problems specific to nursing research (student care and nursing practice); and

Uses school-based data to identify patterns and trends in student health and health services programs.

the expert school nurse: Uses evidence-based research to develop, implement and disseminate policies and protocols (health and academic) of practice; and

Designs and conducts research and contributes to school nursing literature.

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standard 14: resource utilization

the school nurse considers factors related to safety, effectiveness, cost and impact on practice in the planning and delivery of school nursing services.

the emergent school nurse: the competent school nurse: the proficient school nurse: the expert school nurse:

With supervision, assigns or delegates tasks to school personnel as defined by the Connecticut Nurse Practice Act and Declaratory Rulings, and other relevant statutes and regulations; and

Follows district procedures for purchasing and maintaining health office supplies and equipment.

Independently assigns or delegates tasks to school personnel;

Assists students and families in securing appropriate services within the school and community; and

Participates in the budgetary process of the school health office.

Considers factors such as safety, effectiveness, cost and impact on practice when choosing interventions that result in desired student outcomes; and Informs students and families about health promotion, health education, school health services and individualized health interventions for students within the limitations of school resources.

Plans and evaluates school health programs that consider cost effectiveness, cost-benefit and efficiency factors; and Independently seeks resources (grant-writing, special funds, etc.) for appropriate school health programs.

standard 15: leadership

the school nurse provides leadership in the professional practice setting and the profession.

the emergent school nurse: Is recognized as a team

participant who demonstrates energy, excitement and a passion for quality work.

the competent school nurse: Encourages lifelong practice of healthy behaviors for self and school community;

Maintains active member status in state and national professional organizations;

Demonstrates knowledge of the philosophy and mission of the school district; and

Pursues national certification as a school nurse.

the proficient school nurse: Convenes a multidisciplinary team, including relevant school and community members, to address health needs of students and the school community; Maintains national certification as a school nurse;

Promotes active member status and contributes to local, state and national professional organizations through committee work; and Serves in formal and informal leadership roles within the school community.

the expert school nurse: Organizes and facilitates a coordinated approach to school health by serving as a leader for the school health council; Models the use of critical thinking skills, risk taking and data-driven decision making to foster a learning community; and

Serves in formal and informal leadership roles in professional organizations and committees at the local, state or national level.

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standard 16: program management

the school nurse manages school health services.

the emergent school nurse: Maintains an organized health room in an efficient manner; and

Uses technology (assistive, informational and medical) to effectively manage school health programs.

the competent school nurse: Demonstrates knowledge of existing school health programs and current pediatric and adolescent health trends that may impact client care; Implements needed health programs using a program planning process; Orients, trains, supervises and evaluates health aides and assistants; and

Participates on school teams to manage environmental health and safety issues in the school building.

the proficient school nurse: Conducts school health program needs assessments to identify current health problems and the need for revising or developing new programs;

Initiates changes in the school health program based on the results of a school health needs assessment, data analysis and quality care activities; and Provides leadership for teams to manage environmental health and safety issues in the school building.

the expert school nurse: Evaluates ongoing school health programs for effectiveness and efficiency and communicates findings to administrators, boards of education and boards of health, as appropriate; Secures resources, such as staffing and technology, to efficiently provide district school health services; and

Develops systemwide strategies in response to problem analysis.

(28)

super

vision

oVerVIew

The American Nurses Association (ANA, 2000) believes that it is the employer’s responsibility to provide an environment that is conducive to competent clinical practice. This responsibility includes supervision.

Supervision is initial and ongoing direction, procedural guidance, observation and evaluation (Ohio BON, 2001).

The National Association of School Nurses’ position statement, School Nurse Supervision and Evaluation (NASN, 2003), states that “it is essential to provide supervision and evaluation of school nurses by school nurses knowledgeable in school nursing practice, supervision and administration, and that evaluations should be based on standards of professional school nursing practice.” Supervision should be provided through an ongoing, positive, systematic, collaborative process between the school nurses and the school nurse supervisor. School nurses should be supervised and evaluated by someone who has the knowledge and ability to assess “clinical knowledge, nursing diagnostics, judgment, action and intervention” (Periard, Knecht and Birchmeier, 1999).

sUPerVIsIon reQUIrements

School districts should provide adequate clinical supervision and professional resources to meet the needs of their school nursing staff members. Clinical supervision of school nursing requires discipline-specific training and expertise (CSDE, 2004) and experience in the practice of school nursing and school health or a related clinical setting. A school nurse supervisor should be designated by a school system to respond to practice issues in school nursing and school health, such as appropriate assessment techniques, best practice methods and skill-building in all role functions.

Supervision should be offered on an individual basis for all staff members, including new school nurses, interns and veteran school nurses.

• For new school nurses, direct on-site supervision should be provided for two hours weekly — at a minimum —

and consultation by telecommunications should be available as needed.

• Individual clinical supervision for experienced school nurses should be arranged, based on individual and district

needs, ranging from two hours on-site biweekly to biannual evaluations.

clInIcAl sUPerVIsIon And AdmInIstrAtIVe sUPerVIsIon —

How Are tHeY dIfferent?

Clinical supervision requires specialized, professional knowledge, skills and related credentials for the practice of school nursing. It promotes, enhances and updates the professional growth of school nurses in terms of their professional and clinical skills and knowledge. As it relates to school nursing, the term supervision incorporates activities performed at two levels.

• At the individual level, clinical supervision refers to direct, on-site supervisory sessions between the school nurse

and the supervising school nurse. These sessions are designed to improve clinical knowledge and skills related to nursing assessment, diagnosis, planning, evaluation, consultation and other school nurse role requirements.

• Group supervision has the same goal — the enhancement of clinical competencies — but refers to sessions with

a group of two or more school nurses and the supervising school nurse. Group and individual clinical supervision require technical proficiency in school nursing and should only be provided by a qualified school nurse supervisor who has training and experience in the areas of supervision and evaluation (CSDE, 1999; NASN, 2003).

(29)

Administrative supervision may be provided by appropriately credentialed individuals who are knowledgeable about school nursing, such as a building or district administrator (CSDE, 2001). Administrative supervision includes activities and attributes such as adherence to school policy and state and federal regulations, organization, oral and written communication skills, collaborative skills and the day-to-day nonclinical duties performed by the school nurse.

models of sUPerVIsIon

School nurses should receive clinical supervision from a registered nurse supervisor.

The National Association of State School Nurse Consultants’ (NASSNC) 2007 position paper addresses the rationale for clinical supervision of school nurses being provided by licensed, experienced registered nurses rather than a non-nurse supervisor. Several boards of nursing require that nurses be supervised and evaluated by another RN. The Ohio Board of Nursing (2001) specifically states in its regulations that “supervision and evaluation of the practice of nursing be performed by RNs only.” The Kansas Nurse Practice Act requires that “an individual must be licensed to supervise the nursing process. A non-nurse could not supervise nursing practice.” And a growing body of evidence supports nurses being clinically supervised by nurses.

While Connecticut’s Board of Nursing does not include specific language that requires a nurse to be supervised clinically by another nurse, best practice, legal prudence and professional integrity direct that clinical supervision should be performed by nurses. The nurse supervisor can evaluate and guide the job performance of the nursing staff with “an eye toward risk reduction and improved program outcomes.” (Descoteaux, 2001)

As school districts strive to move toward a model of school nurse supervision, the following models may be used:

clinical supervision at the district level

This model is the benchmark that all school districts should strive to attain.

NASSNC (2007) defines clinical supervision as “a formal process of professional support and learning which enables individual school nurses to develop knowledge and competence, assume responsibility for their own practice and enhance client protection, school nursing practice, and the safety or care in complex clinical situations. This clinical supervision is a practice-focused professional relationship involving a practitioner reflecting on practice, guided by a skilled nursing supervisor.”

In this model a school nurse supervisor guides, supports and responds to emergent practice issues and evaluates the school nurse’s clinical performance.

supervision by non-nursing personnel

In school districts where the supervisor or administrator is not a school nurse, administrative supervision should be provided. A non-nurse administrator cannot address the need for staff support and professional growth, issues that can be addressed only by a school nurse administrator. If school districts do not have an administrator who is a school nurse supervisor, it is recommended that a designated lead school nurse provide clinical supervision. Other innovative arrangements for evaluating and supervising school nurses (and other support services specialists) might be explored. School systems may need to share supervisors with other districts, develop regional models or appoint a lead school nurse on a part-time basis. School systems also may contract with their regional educational service centers for clinical consultation.

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regional models

• Regional educational service centers (RESCs) are public education agencies created under state statute

primarily for the purpose of “cooperative action to furnish programs and services” to public school districts. Cooperative efforts of RESCs have saved money for Connecticut school districts over the past 30 years and have enabled schools to expand services beyond what they could have accomplished alone.

RESCs do what their school districts need them to do. They support both the instructional and operational sides of school districts. In providing programs and services to schools, RESCs may be well-suited to develop regional school nursing supervision for small public school districts in their service areas. Many small school districts do not have the individual resources to have a nursing supervisor but would be able to contribute to a regional system through a RESC.

• Regional school districts, similar to the RESC model described above, that do not have school nurse

supervision in each town may partner with the towns in their region at both the elementary and secondary levels to provide nursing supervision to the entire region.

All models of supervision described above should include nurse supervisor visits to each local public school district throughout the school year, evaluation/performance appraisals for individual school nurses, regularly scheduled nursing meetings with all districts, individual consultation as needed, assistance with the development of policies and procedures, and when appropriate, professional development opportunities for school nurses.

Peer/group supervision

Peer/group supervision is another viable source for staff supervision and development. In this model, competent school nurses with experience can assist new school nurses to function more effectively in their positions and to improve their clinical knowledge and skills. By offering technical assistance, being available for questions and providing support, the new school nurse is supported by someone with clinical experience and technical proficiency.

Peer mentoring

While not a substitute for school nurse supervision, peer mentoring is another means of ensuring sufficient opportunities for professional growth and development for novice school nurses. Houghton’s 2003 study on school mentoring finds that it is “crucial to the success of school nursing to offer mentorships and continuing education to individual school nurses. There is an increased demand for experienced and knowledgeable school nurses due to the challenging health, social and emotional needs of today’s school-age children… assisting new school nurses to acquire the knowledge and skills necessary to improve the health outcomes of children is essential in today’s schools.”

ProfessIonAl deVeloPment

Ongoing professional development is the means by which school nurses maintain, improve and broaden their knowledge and skills and develop the vision to provide quality nursing services that are current and meet the needs of the children and youth they serve. “Nursing professional development is the lifelong process of active participation by nurses in learning activities that assist in developing and maintaining their continuing competence, enhance their professional practice and support achievement of their career goals. Nursing professional development builds on the educational and experiential bases of nurses throughout their professional careers, with the ultimate goal of ensuring the quality of health care to the public” (American Nurses Association, 2000; NASN, 2006).

Supervision also includes providing professional development activities offered through department meetings, workshops and conferences. These activities are part of a comprehensive clinical supervision plan developed for the school nursing staff. Professional development days offer an excellent opportunity for school nurses to pursue leadership opportunities,